Get Support Information Form

Please Read First:

The Pregnant with Cancer Network is a national non-profit organization for women diagnosed with cancer during pregnancy.  Our mission is to connect women who are pregnant with cancer with other women who have been pregnant with the same type of cancer.  These women are here to lend support, offer hope and share their experiences with one another through phone and e-mail conversation.

If you are pregnant with cancer and would like to speak with a support woman please fill out the information below, or call 1-800-743-4471. 

If you are a interested in becoming a support woman please click here.

NOTE: Fields marked with * are required. If unsure of answer, please indicate so.

First Name:
 *
Last Name:
 *
Street Address:
 *
City:
 *
State:
 *
Zip Code:
 *
Country:
 *
If outside US, please
type entire address as it
should appear on
envelope:
 Line 1:
Line 2:
Line 3:
Line 4:
Line 5:
Phone:
(Include Area Code)
Best time to call:
Fax Number:
(Include Area Code)
Email Address:
Language:
Preferred method of contact:
Type of Cancer:
 *
What stage is the cancer?
If Breast Cancer, what type?
Date Diagnosed:
 *
(Must at least have the 4 digit year entered -
Format: yyyy-mm-dd)
Number of weeks pregnant when diagnosed:
*
Type of surgery you had / was recommended:
Type of therapy/treatment you had:
*
If your therapy/treatment is
not listed above please enter it here:
Your age at diagnosis:
*
Yes, I am interested in speaking with a support woman, please contact me.
Please connect me with a support woman, whom I will contact.
Please add my name to the  mailing list to receive your newsletter.
Please send me a PWCN packet of information.
   

If you have another type of request, please describe it in the explanation section below.
Detailed explanation of request (if required):
   
Your Questions or Feedback
Please enter your questions or feedback in the field below.
How did you hear about us?
If other, please specify:
I would be interested in becoming a support woman in the future.


The content of form submissions and email messages will be treated as personal and private
correspondence and will not be published or distributed in any way.